HowdidwegofromSGRtoMACRA(whatisMACRA?)

Cathie Biga Ohio ACC

October 15, 2016 cbiga@cardiacmgmt.com

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Cathleen Biga, MSN, RN: Disclosures: •  Co-chair:ACCCVAdministratorWorkGroup•  Member:CardiovascularManagementCouncil•  Member:HealthAffairsCommi@ee•  Member:BOTWorkGrouponMedicalandProfessionalLiabilityInsurance•  Member:CQCAUCImplementaKon&EvaluaKon•  Member:CQCFOCUSCommi@ee•  Member:PartnersinQualityCommi@ee•  Member:TaskForceonMACRA•  OwnershipInterest/Partnership/Principal:CardiovascularManagementofIllinois•  ConsultantFees/Honoraria:Medaxiom•  OrganizaKonal(Non-Commercial):CardiologyAdvocacyAlliance•  OrganizaKonal(Non-Commercial):MedaxiomAdvisoryBoard

Whatistheproblem…..

Where are we…..how do we get there

Themarchtovalue……..

ThetrainhasleZthestaKon,anditain’tcomingback

MDRevenueatrisk2017&2018

Source: MGMA

ValueAgenda:Physician•  MeaningfulUse•  PQRS•  ValueModifier•  QRUR•  S-QRUR•  PhysicianCompare

•  HelloMACRA•  MIPs–Quality60%,Cost0%,ACI25%,CPIA15%

2014

2015

Astheworldturns…..

For more information, visit: ACC.org/CVSummit17

HowdidwegettoMACRA?1997

• MedicareSustainableGrowthRate(SGR)implementedaspartoftheBalancedBudgetControlActof1997

2002-2015

•  17patchestoavertsteepcutstoMedicare•  HouseofMedicine,includingtheACC,workswithCongresstocraZMACRA

March24,2015

•  H.R.2(MedicareAccessandCHIPReauthorizaLonActof2015)introducedintheHouse

March26,2015

•  TheHousepassedH.R.2(392-37)

April14,2015

•  TheSenatepassedH.R.2(92-8)

April16,2015

• MACRAsignedintolawbyPresidentBarackObama

TheBasicsofMACRA

•  MedicareAccessandCHIPReauthorizaKonAct•  EliminateSGR•  EffecKve1/1/19•  MACRA•  APM:baseyearwillbe2017

•  Thenewfinalrulehassomechangesin“qualifyingAPM’s”•  MIPS:baseyearwillbe2017

Practices will have choices under MACRA"

•  Statutory updates"•  Consolidated reporting"•  Reduced penalty risk"

Fee-for-Service under a “Merit-based Incentive

Payment System” (MIPS)"

•  Higher updates"•  Exempt from MIPS"•  Preferred treatment for medical

homes"•  Specialty models encouraged"

Alternative Payment Models"

MUrequirements:25points•  Performancescore•  BaseScore•  5measures

•  Earnfullpoints•  Therewere11•  TheothersareopKonal

ClinicalPracLceImprovement(15points)•  90acKviKes•  Pick4mediumor2high•  40points

Quality/PQRS:60points•  6qualitymeasures•  1sub-specialtymeasure

set•  Webinterfacerules

different ResourceUse:0points

•  MSPB•  Totalcostofcare•  Episodesofcare

•  Only10vs40•  Onlyonesins-QRUR

•  30%by2021

MIPSCompositeScore

Quality50%

QualityUse:60%

Changes•  2017willbeatransiKonyear•  QualityisKing•  Costiscollectedbutnotscored…..yet•  APM•  LookingatanACOTrack1+•  Detailsnotoutyet•  LookingatPrivatepayer&Medicaid

•  Excludedproviders:$30Kor100paKents

LatestonMACRA•  PickyourPace:PYP•  Announced9/8–moredetailstoday•  ForreporKngyear2017ONLY

•  1measurefromeachofthe3•  NonegaKveadjustment•  IfyoudoNOTHING=4%

•  OpKon2:ParKcipateforaparKalyear•  90days•  Morethan1measurefromthe3categories•  CouldgetaposiKveadjustment

PYP:conKnued•  OpKon3:ParKcipateforthefullyear•  Youcouldbeeligiblefora“modest”posiKvepayment

adjustment•  OpKon4:JoinaQualifiedACO•  MSSPTrack1,2or3–YEA!!!•  5%bonusIFqualifyingproviderQRURisoutands-QRURshouldbereleasednextweekStaytunedforthefinalMACRAruleinearlyNovember

Pickyourpace:

ACOAlert

•  QualifyingAPM•  MSSPTrack2&3•  NextGen•  Pioneer•  CPCI+•  Oncology•  MaybeMSSPtrack1+•  ??CMSmandatedbundles

•  APM–Doesn’tqualify‘17•  MedicareSharedSavings

Track1•  BPCI

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Howdowereport

•  Individual•  Electronichealthrecord•  Registry•  QCDR:qualifiedclinical

dataregistry•  Medicareclaims

process.

•  Group•  CMSwebinterface•  Electronichealthrecord•  Registry•  QCDR:qualifiedclinical

dataregistry.

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WebinterfaceMUSTapplyby6/30

Quality:60%

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ACI:Required

ACI:Bonus

AdvancingCareInformaKon–25%

•  ACIakaMU–131points•  ReplacestheMedicareEHRprogram•  NewemphasisoninteroperabilityandinformaKonexchange•  Eliminatesthecurrentallornothingprogram

•  'Failuretomeetthesubmissionrequirements,ormeasurespecificaKonsforanymeasureinanyoftheobjecKveswouldresultinascoreofzerofortheAdvancingCareInformaKonperformancecategorybasescore

•  RemovedeCQM’sfromrequirements•  Therewillbeatotalof130pointsavailable–basescore+performance

•  +1bonuspointavailable•  100pointswillallowyoutoclaimthe25%ofthiscategory

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ClinicalPracKceImprovement:CPI

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RatedasHighandMedium

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Cost

•  0%foryearone•  Threecostmeasures•  Totalcostperbeneficiary•  MSPB•  10episodesofcareONLYthoseins-QRUR

•  OnlyCABGandValvesurgeryinfinallist

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A@ribuKon&Risk

•  A@ribuKoniscriKcal•  QRUR2stepa@ribuKonmethod•  AddingChroniccarecodes•  AddingSNFcodes

•  PartAandPartBcostsfor1year•  RiskscoresarecriKcal

MSPB

•  InpaKentonly•  A@ribuKon •  Pluralityofclaims(asmeasuredbyallowablecharges)

•  Cost3dayspreand30dayspost

APMs "•  APM is a generic term describing a payment model in which providers

take responsibility for cost and quality performance and receive payments to support the services designed to achieve high value"

•  According to MACRA, APMs include:"−  Medicare Shared Savings Program ACOs – Track 2 & 3 ONLY"

−  CPCI +"

−  Pioneer & Next Gen"

−  Onc model"

−  ??? New CMS Mandated cardiac bundles"

Therearereally3“Buckets”

QualifyingACOANDQualifyingProvider

AreYouMACRAReady?•  OrganizaKonalfocus•  Physicianledprocess•  Currentlysuccessfulin

•  PQRS•  MU•  VM–QRURands-QRUR

•  Youhavefoundyourdata•  Youknowyournumbers

•  Reducingvariabilityincaredelivery–MUSThappen

•  Understandingcost•  Understandingepisodesof

care•  CarecoordinaKonisan

organizaKonalpriority•  DocumentaKonisafocus–

clinic&hosp.

2017–NoAdjustment

QualityMeasures

SupplementalQRUR

AnatomyofanEpisode•  StructuredpaymentaroundapaKentsTOTALexperienceof

care•  Quality–outcome•  Cost•  Experience

•  Preandposthospital•  OZen3dayspreand90dayspost

•  Be@ercoordinaKonofcare•  UlKmatelybe@erpaKentoutcome

Episodesofcare-historical•  ACEproject:testedbundledpaymentsinearly2000’s

•  Cardiacandortho•  Orthowidelysuccessful•  Medicaresavingswhilemaintainingquality

•  1990’sBundledpaymentsCABG•  Successfulinreducingcost,improvedquality,andprovidedservicesmoreefficiently

•  BPCI:CMMIproject•  OrthoMandatedbundle

Episodesin2016•  Componentofthes-QRUR-64episodes

•  CondiKonepisodes•  Proceduralepisodes•  40ofthesewilltransfertoMIPscostcategory

•  LAN–•  Maternity•  Orthobundle•  CADbundlewithnestedprocedures

•  CMSmandatedbundles•  4/1/16–ortho(CJRin67MetropolitanStaKsKcalAreas)•  7/25/16–MI/PCI,CABG,expansionofortho(SHFFT)

Basicepisode

So…..dowerun……or

Thebasics•  WillbemandatedinspecificMetropolitanStaKsKcalareas–394naKonally•  SpecificAMIcriteriaapplied•  294MSA’sremained•  98MSA’swillbe“selected”–endof2016•  12inIL–only1excluded

•  AllMedicareFFSpaKents•  2cardiacbundles–firstKmecondiKon+procedure/surgerycontainedwithin1bundle

Thebasics•  MI–includesMIANDMI+PCI

•  IncludesbothprimaryANDsecondarydxcode•  OutptMI’snotincluded(naKonallythisis6%)

•  CABG•  Starts7/1/17•  Willlastfor5years•  PartAandPartBcostincluded(plushospice)•  1/1/17thru12/31/18–2/3localdata+1/3regional

•  2019=yr.3=1/3local+2/3regional•  2020-2021=allregional

CardiacRehabIncenKve•  AddiKonalprogram

•  45ofthe98randomlyselected+•  45selectedMSA’sthatarenotpartoftheEPM

•  Cardiacrehabandintensiverehabprograms•  $25pervisitfrom1-11•  $175pervisitfrom12-36•  Can’tbeincludedinFSA•  Won’tbecountedinreconciliaKonpayments•  CanprovidetransportaKon•  UseofAPP’s

Andso…..WhatcanYOUdo…•  Ensurecodingisaccurate•  UnderstandYOURcurrentqualitythresholds•  FindyourNCDRdata---reviewit•  Knowyourdata–PQRS,MU,QRUR,ands-QRUR•  EstablishdataanalyKcsandinformaKonsharing•  ReducevariaKonincareacrosstheSystem•  CreatetheinfrastructureandexperKsetocoordinatecaretransiKonsandmanagepost-acuteservices

LeadingtheCharge

•  Designconsistentcarepathwaysacrossyourhospital–forEVERYONE

•  FacilitatecommunicaKonamongsttheteam•  ED,PCP,SNFmedicaldirectors,APP’s,hospitalists

•  Knowyourcostpercase–leadthechargeincostreducKonthatresultsinexcepKonaloutcomes

•  Don’tbeafraidofre-designingyourphysicianworkforce

QuesKons?

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For more information, visit: ACC.org/CVSummit17